HomeMy WebLinkAboutVOYLES BLK 2 LT 5•Q�m
inspection Neport_i-i-iz.00c
Municipality of Anchorage
Community Development Department Page 1 of 2
On -Site Water and Wastewater Program
4700 Elmore St. - P.O. Box 196650 Anchorage, AK 99519-6650 - http://www.muni.org/onsite - (907) 343-7904
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP1 71337
PID Number: 051-064-67 F71 New 2 Upgrade
Name:
ALLEN ROHDE
ABSORPTION FIELD
El Deep Trench R Shallow Trench FZ1 Bed El Mound
Address
23501 CHANDELLE DRIVE
El Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
1 6
0.5GPD/SF1
0.5 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
0.0 Ft.
Gravel depth beneath pipe
0.5 Ft,
Subdivision
Block Lot
VOYLES
2 5
Fill added above original grade
-Z C;t
Gravel length
65 Ft.
Township Range Section
Gravel width
28.0 Ft.
Beds: Number of Lines
5
Distance between lines
6 Ft.
SEPARATION DISTANCES
Tol
Septic
Absorption
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Lift Station Tank
Line
1820 FC
N/A
Ft.
Well
149.2
170.0
jt
i 163.8 1 N/A
132.1
TANK 121 Septic 0 S.T.E.P. 171 Holding El Other
Manufacturer
ANCHORAGE TANK
Capacity
2000G,I.
Surface Water
100+
100+
100+ N/A
—
Material
Number of compartments
Lot Line
803
44.7
80.0 N/A
STEEL
2
NA
Foundation
1 16.9
41.3
32.1 N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
bO+
bU+
50+ N/A
ORENCO
500 Gal.
Remarks
Pump on level at
43 in.
Pump off level at
40 in.
High water alarm at
45 in.
Pump make and model
P2005
Electrical Inspections performed by
Installer
PIPE MATERIAL Housetotank Tank to 3034
3034 drainfield
JR'S SEPTIC SERVICES
Drainfield 3034 CO/MT 3034
Inspector PANNONE ENGINEERING SERVICES
BENCH MARK' (Assumed elevation) 367 ft
InspectionLocation
dates: 1" 11/28/17
2"' 11/29/17
and description
3`d 08/8/18
4th
NW BOTTOM HOUSE TRIM
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
Conditional Approval:
Date•
OF k,
teven
.annoRe
CE 8149
Approved
Date f L
Awl
inspection Neport_i-i-iz.00c
41EXTENT OF FILLZ.6BR RESERVE AREA BASEDELL E ON CATIll SYSTEM (NIC)PER MOA CODETH3 1994TR EUNTH2 1994)MIH20 MONITORINGMT INSTALLED 20OCT17H20 0 3:0H20 MONITORING 06novl7 —SOIL PROFILE SIMILAR TO THI TINSTALLED DRAIN FIELDW/ —1.0' COARSE SAND LAYER BENEATHW/MTs AT CORNERS OF BED
REMOVED 1250a SEPTIC TANK
[A TANK
ADDED 2^R1 AND PLACED RLL REQUIRE
TO MEET 3' COVER OVER FIELDBDR
| /
SFDDESIGN PARAMETERS/
UPGRADE PRIMARY SEPTIC SYSTEM 14{
| NO. BEDROOM: G(9�Ugpd)
TANK SIZE: 20OOg
|
` � /
=�.� "MI=,. . '� _
SOIL RATING: O.5GPD/SF / | //� l*y2
AREA ROD: 1800 SF
5Y3. TYPE' BED 0.5'ED
\
MIN SIZE: 75LFx24\Y | �
| |
USED: /
|
55LFx28'wx0 5'E D D 5'TD � �`� ��
TOTAL AREA: 1820 SF
20OOg SEPTIC
TANK
I NOTES:
I RECORD DRAWING
I REVISED PER MOA COMMENTS
1 11/2/2018
DRAWN ACP I
Sl TE PLAN -1
PROF/LE
SCALE: NTS
PAMONE ENG SVC, LLC
P.O. BOX 102954 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
VOYLE3 82 L5
SITE ADDRESS: 33501 CHANDELLE DR
ALLEN G R(}HOE
11935 OLD GLENN HWY STE 201
EAGLE R|VER, AK 99577
F'o.
351.5
T2
32.2
62.8
LS
�
64.9
�
D=
�
71 8
� �
°
0-
77.3
71.7
�
�
uc U
20OOg SEPTIC
TANK
I NOTES:
I RECORD DRAWING
I REVISED PER MOA COMMENTS
1 11/2/2018
DRAWN ACP I
Sl TE PLAN -1
PROF/LE
SCALE: NTS
PAMONE ENG SVC, LLC
P.O. BOX 102954 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
VOYLE3 82 L5
SITE ADDRESS: 33501 CHANDELLE DR
ALLEN G R(}HOE
11935 OLD GLENN HWY STE 201
EAGLE R|VER, AK 99577
F'o.
351.5
T2
32.2
62.8
LS
356
64.9
M2
71 8
101.9
M3
77.3
71.7
351.5
Date
08/08/18
Scale
MUNICIPALITY OF ANCHORAGE �,cnr
On-Site Water&Wastewater Program �� 3
�;
, PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax: (907)343-7997
http:llwww.muni.orglonsite •
D partmcnt
,'YCM O0.�GE
On-Site Wastewater Disposal System Permit
Permit Number: OSP171337 Effective Date: 11/8/2017
Work Type: Septic Upgrade Expiration Date: 11/8/2018
Tax Code Number: 05106467000
Site Legal Address: VOYLES BLK 2 LT 5 G:1460
Site Mailing Address: 23501 CHANDELLE DR, Chugiak
Owner: ROHDE ALLEN G & Lot Size in Sq Ft: 50012
Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 6
This permit is for the construction of:
0 Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well 0 Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
•
Received By: Date: IC/
Issued By: 1621T...e/L. • . ' Date: Ili 8/ ZO 17
MUNICIPALITY OF ANCHORAGE
Community Developmentment Depart70 Pho, -� •I,•
Development Services Division a 9• - • •7
On-Site Water& Wastewater Program 4 OCT 3 0 2017
ON-SITE SEWER/WELL PERMIT APPLICATION 11. 5 ,,,
4, CL 6 3 L
Parcel I.D.
051-064-67
Property owner(s) ALLEN G ROHDE Day phone
Mailing address 11925 OLD GLENN HIGHWAY STE 201
Site address 23501 CHANDELLE DR
Legal description (Sub'd., Block & Lot) VOYLES B2 L5
Legal description (Township, Range & Section)
Lot Size 50,012 Sq. Ft. Number of Bedrooms 6
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑X Initial ❑ Single Family (SF) ❑X
(w/wo ADU)
Septic Tank ❑X Upgrade ❑X Duplex (D) ❑
Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage I
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
1
IP 44, 1
(Signature of property owner or authorized agent)
Permit/Rush Fees: Waiver Fees:
Date of Payment: 1013010- Date of Payment:
Receipt Number: iL56 Receipt Number:
Permit No. 16°17• Waiver No.
Permit App_ - :: ..c
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail:steve@panenRak.com
November 7, 2017
Subject: VOYLES B2 L5
Septic System Permit Request
Design Narrative
This is a design narrative for a permit to install an upgrade septic system to be issued for this property.The proposed system will
serve an existing house upgrading from four(4) bedroom to six(6)bedroom. Currently the lot is developed.The proposed
system will remain a conventional waste water system with an absorption bed. The surrounding lots are served by private
wells.There are no wells within 100'of the proposed septic system
I. Soils.A test hole was performed in the vicinity of the proposed system by Mike Anderson in December of 1994,and
groundwater was monitored for at least seven days. Ground water was observed to a depth of 7' below the surface in the
test hole monitor tube in January 1995. Based on the results of the percolation test an application rate of 0.5
gallons/day/square feet was used for a bed system in the area of this test hole. PES conducted a test hole in the vicinity of
the proposed bed expansion to confirm soil profile and ground water on October 20, 2017. Ground water was observed to
a depth of 5' (seasonal high)below the surface in the area of the test hole monitor tube in October 27,2017.
2. Soil Absorption System Design.
a. See Sheet 1 of the design package.
3. Surface Water:There is no surface water within 100 feet of the proposed wastewater system.
4. Topography:The existing overall topography slopes up from the north to the south at approximately 10%-20%_ The slope
in the area of the proposed system are approximately 10%-15%. There are no steep slopes within 50'of the proposed drain
field (see waivers).
5. Drawing Markings:The Drawings are marked "For MoA Review Only".When written notification that the review is
complete and that there are no further comments is received from MoA On-Site Department, the note will be removed and
"Issued for Construction"drawings will be issued.
The proposed installation will not affect the future development of this or the surrounding lots.
Mailing: P.O. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
DESIGN PARAMETERS _w —w — WATER LINE /
—UPGRADE PRIMARY SEPTIC SYSTEM WELL RADIUS .�
NO. BEDROOM: 6(900 gpd) " -1*t:,
TANK SIZE: 2000g 4,\ * S
PERC RATE: 15 MPI —ss —ss — NEW SEPTIC ti,* **
SOIL RATING: 0.5 GPD/SF ** „ i c5
w
AREA RQD: 1800 SF ABBREVIATIONS ',,r lie,,,t. i
,
SYS. TYPE: BED 0.5'ED TH TEST HOLE -
MIN SIZE: 75LFx24'W
_ (P) PROPOSED
TRUE NORTH oso, SCALE : 1 50'
USE: (E) EXISTING
65LFx28'Wx0.5'E.D.,0.5'T.D. 'CO CLEAN OUT NO. I
TOTAL AREA: 1820 SF _MT MONITOR TUBE NO. / / I
/ '/ \TYP TYPICAL — ` __ / I
/ /
1 EXTENT OF FILL(P) ( \
—
6BR RESERVE AREA BASED 1 \ IssD •
ON CATIII SYSTEM (NIC) ` _
/ - - ®\fi \
/ TH3 1994 \ _
I \ �
TH1 1994 \ — _ _
hRIN A lillik \_ TH21994� \
\ i i \I\ \ -- .,...
H (��_
IMillir
N
H2O MONITORING \
MT INSTALLED 20OCT17pir, �; i \
H2O MONITORING 270CT17 — H2O 0 5.0' -- .. — _
H2O MONITORING 06nov17 — H2O 0 3.0' `SOIL PROFILE SIMILAR TO TH1 I -N-
I
N � y
II I I / 1 I INSTALL 2000G SEPTIC TANK &
/I( iI 500G AUX PUMP TANKP)
R&R ABSORPTION FIELD PER MOA CODE(P) REMOVE 1250G SEPTIC TANK(E)
65LFx28.0'Wx0.5'E.D.,0.5'T.D. /
W/ —1.0' COARSE SAND LAYER BENEATH Sc / ,M—~ M �)
W/MTs COs AT ENDS OF BED,
ADD 2"R.I. AND PLACE FILL REQUIRED TO -3701
MEET 3' COVER OVER FIELD / \ — /
1 I 1 I
\ _ \
� 1 \ I � \ 1
I7 \ � I
WELL (E)„....-------°. .
I - . / 1
I '
LM / WELD (E)
__ if,. ,/,,,,,,____
��\ _ M _ HNDEL-LE_ Drives_ _ _ _
1 /
/ \ 17 ,. - 14/ ,_ \iv
1 / /
NOTES: PANNONE ENG SVC, LLCDate
FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 4••' 11/07/17
PHONE (907) 272-8218 FAX (907) 272-8211P'• lit
•• • Scale
*I . •* 1" = 50'
VOYLES B2 L5 , •••••• ' •• P.I.D. NO
SITE ADDRESS: 23501 CHANDELLE D' - �� .•- 051-064-67
• }ems will' a PERMIT NO.
DRAWN JRL ALLEN G ROHDE CE 81491
11925 OLD GLENN HWY STE 201 '4 %F�:.RFV.11/0R/1; OSP171337
'
SITE PLAN EAGLE RIVER, AK 99577 '' •• as Sheet1 OF 2
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF
ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF
ON—SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55.
2. SCOPE OF WORK: UPGRADE SEPTIC SYSTEM (BED & TANK) FROM FOUR(4) TO SIX(6) BEDROOM.
3. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 5 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL
TEST HOLE. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 5 FEET BELOW
EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY.
4. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC
LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED
SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK.
5. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED.
6. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES.
7. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING
AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER.
8. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE
CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN.
9. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED—LINE AS—BUILT DRAWINGS TO THE
ENGINEER. THE RED—LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND
TANK ELEVATIONS.
10. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION,
TOP OF PIPE WITH CLEAN—OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING.
11. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE
PROJECT AS CONSTRUCTED. THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY THE ENGINEER
(OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE
CONTRACTOR.
12. THE CONTRACTOR SHALL SIGN THE FOLLOWING:
I CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE
ORDERS, AND THAT THE AS—BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS
CONSTRUCTED.
CONTRACTOR:
BY: . TITLE:
DATE:
NOTES: i LLC Dote
FOR CONSTRUCTION PANNONE ENG SVC, LLC 10/27/17
P.O. BOX 102954 ANCHORAGE, AK 99510 p' '••'"
PHONE (907) 272-8218 FAX (907) 272-8211 • 1, Scale
• • I •* NTS
VOYLES B2 L5 ; •••• 44410•' ' "' P.I.D. NO
SITE ADDRESS: 23501 CHANDELLE DR —gown •• •••• o5i—osa—s7
eVefl O�In011e PERMIT NO.
DRAWN —I JRL ALLEN G ROHDE CE 814 _ osPxxxxxx
11925 OLD GLENN HWY STE 201 + '•RFV 11/08/?
DESIGN NOTES EAGLE RIVER, AK 99577 '`��q s 1 Sheet
OF 2
Municipality of Anchorage Page I of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~H// ~-¢'~:~/'¢~ PID Number:
.ar.e: /~ IV~ 4- ~ C~l~ Wastewater System: ~w u Upgrade
Address:~0, lOX ~Oy~5 ~/~ ,4~ ABSORPTIONFIELD.
No. of Bedrooms:
Phone: ~ ~ [~ ~OO~ ~ Deep Trench U Shallow Trench ~ UMound UOther
Total Depth from original rade~
LEGAL DESCRIPTION So,,~b.g: .¢ ~/Sq.~h ¢
Depth ~o pipe b01t0m from ori inat grade: Gravel depth beneath
Block: Subdivision:
Section:
Township: Range: F added above original grade: Gravel length:
~ ]' ~ Ft. ~ Ft.
WELL: ~'ew 0 Upgrade Gravel width: ~ Ft. Number~lines: Oista.cebetweenlines:~ Ft.
Classilication~Private A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material:~5~
Date i stalled:
Date rilled:
Yield; Casing Height Above Ground:
/~ GPM Pump Set at: [tI ~ Ft. TANK
SEPARATION DISTANCES ~tic ~ Holding U S.T.E.P.
TO Septfc Absorphon Lgt Holding =ublic/Private Manufacturer: Capacity in
From ~ank F,eld S,a,,on T~nk SewerLine, ~. r~ ~ ~ ~0
Surlace
Water )/0¢1 >/¢~' / / / LIFT STATION
// Location and Description:
ENGINEER'S SEAL
Inspections pedormod By Datos: ~st~ ·
Department of~ ~lth an ~,~ ~,set~es approval , :'" '. -":~,.,
Reviewed and approve ~ Date:
72-013 (Rev. 9/91) MOA 25
Pe .ri'nit No.
Page
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
of $
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: L-o'r'~'! ~CO~..'Z., ~/~yl.,G~'
PID No.:
Permit No.
Page ~ _of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
FROM : MMM CONTRACTING PHONE NO. : 6881238 Nov. 03 1995 ll:25AM Pi
Phone: 68~-1~36
MM&M CONTRACTING INC.
P. O. BOX 670495
C'HUGIAK, AIL 99567
Novomb~ 2, 1995
P. O. Box 240'/73
~horag~, Ak. 99524
Lot 5 BIo~ :2 Voyles Sub.
Doar Mr. And~on;
The monitor mba b~low fl~ sq~flo was bvnt ~ ~d p~ yo~ ms~ao~ wo ~
' o~od~' fl inlho m~vs~ofoxoava~.
~o ~dth of ~e aopflo ~ w~ m ~ Y P
Wo hopo ~ information is helpful,
FROM : MMM CONTRACTING PHONE NO, : 688t238 Oct. iT 1995 04:47PM P1
· OWNER OF'LAND .... ' ' '..,:.:' '::'.':1 :.' ' '. ..... :. '' · )
ADo~.SS'P~O- ?~?. 6'tO ~.'r.¢' a~'~,,~< :' ST,~T,C' L~.~,O,V,,T',,iv'r. _ :! COq' : ': '!
DATE, Stfiried .... Ended
FERMIT NUMBE~. ......
KIND OF FORMATION:'
OATS. ,e~ .~ .....
Fromm,, Fl. tO , ~t .... . ' rro~ : Ft, tu~F~
From: J~l. to~ FI,
From :PLto FI,,
· Fr~ra~._' .. FL'lo' . Fi,
From.. Ft. ~o~F!
:rom..,,,,, FI. to., ~ FI,
~rom~Ft. to ..... FI,
~om ...... Ft.
From. _FI. to _Fi .....
From . Ft, to .... FI,
From__FLto Fl.
From~Ft. io_ i ' ~! ......
"' From FI.(O : FL
/~F6 ~o /75" .
ro n,-----._Ff, lo ' ,Fl.
IISCL, INFORMATION:
!V'E I;)-- .,
OO.T '1 9 199'5' ...
Municlpaliiy,_. _ _ ....... ,~ ..,,°f Anch..orage. '.'
.... :. .. . ~ Deut...~4~e~,m~.iqumanr4er¥c,~s -..,
:,. -., . · . -,. . .. -, ', . · .... r:.,.,,,,..,!:,. ,.., .,.. . '. ? k~:~
DRILLER
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW950014
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:GRAYBILL JOHN & DOLORES M
OWNER ADDRESS:P.O. BOX 670495
CHUGIAK, AK 99567
PARCEL ID:05106467
DATE ISSUED: 2/10/95
EXPIRATION DATE: 2/10/96
,4A,4AA, q Co~S~
LEGAL DESCRIPTION:
VOYLES BLK 2 LT
5
LOT SIZE: 50012 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
PERMIT)
SPECIAL PROVISIONS:
DATE
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, ALASKA 99524
January 31, 1995
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 5, Block 2, Voyles Subdivision
Septic System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
We hereby request a permit be issued to install a new well and septic
system on the subject lot. A shallow bed system is designed as groundwater
was encountered at a depth of 6.5'. Percolation rates for material
encountered at shallow depths are excellent and the absorption bed should
function adequately to support the four bedroom home. If the system is
constructed as shown on the attached drawings the following statements can
be made.
The system, if constructed as designed, will have no adverse impact on
the wells in the area. The 100' protective radius is shown on the
attached site plan.
The system, if constructed as designed, will have no adverse impact on
existing septic systems in the area or those to be constructed in the
future.
The system, if constructed as
reserved space, either surface
area.
designed, will have no adverse impact on
or subsurface, on any lots located in the
4. The system, if constructed as designed, will have no adverse impact on
drainage patterns in the area. The current drainage pattern will be
maintained.
Sincerely,
Michael E. Anderson, P.E.
LOT 5, BLOCK 2, VOYLES SUBDIVISION
175.00
25
/
SITE PLAN
SCALE 1" = 30'
179.41
('" I-i A klm ~- i I IL-
Lot 5, Block 2, Voyles Subdivision
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Four Bedroom Home Shallow Bed System
Perc. Rate: 15 Min./Inch 1,250 Gal. Septic Tank
Application Rate: .5 GPD/SF Min. 2' Accepting Soil
4 Bdrms. X 150 GPD / .5 GPD/SF = 1,200 SF of Absorption Area
1,200 SF / 24 LF Wide = 50 LF Length
Therefore: Construct a Shallow Bed System 24' Wide X 50' Long at
the Location Shown on the Site Plan. Distribution Pipe Placed at
.5' Above Existing Ground Surface.
*", :'::; .... ' ...... ~',~ ~',~.~) TYPICAL SHALLOW BED SYSTEM
~? ~:-'~ ~:~- ~ .' ~ 'f (NO SCALE)
.;.':'NO~E.~ Maintain 4 Vertical Separation From Bottom
Gronndwater Table.
2' of Coarse Sand Must Be Placed
and Atop the SP/SM Material.
Provide 2" H.I. Insulation Atop
Minimum of 2' of Cover.
of Bed to
Below Drainfield Rock
Bed and Provide a
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
; = : (ENGINE~h'~SEAL)
PERFORMED FOR:
5-
7-
8-
9-
10-
Township, Range, Section:
SLOPE
11
13o
14-
15-
16-
17-
18-
19-
20-
COMMENTS
WASGROUNDWATER
ENCOUNTERED?
SITE PLAN
s
IF YES, AT WHAT ~
DEPTH? p
E
Depth to Water Alter,. ~] '
Menit0rigg? ~' rE. Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
¢¢/ - Vz,, -
~ IZ: ~ I ~ 7 ~/¢ " I"
~ / : ~0 / ~ ~ =/~ " I"
PERCOLATION RATE
TEST RUN BETWEEN
(m~nutes/~nch) PERC HOLE DIAMETER __
FT AND ~.~ FT
~/--~-~ ~ T'/A/6.
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.DATE:
72-008 (Rev. 4/851
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502~0650
SOILS LOG -- PERCOLATION TEST
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
4
COMMENTS
DATE PER F~RME
Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
iF YES, AT WHAT
DEPTH?
Depth to Water After// I Bate'
Monitoring? '~ .
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE / ~* (mlnutes/~nch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ~- FT AND ~'~ FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELtNES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: Lot 5, Block 2, Voyles Subdivision
GENERAL:
The scope of this project includes the procurement and
installation of a 1,250 gallon septic tank and the
construction of a shallow bed drainfield to serve the
proposed four bedroom home.
Construction shall be in accordance with the approved site
plan, design drawings, Municipal Permit with any special
provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
3. The Contractor shall be responsible for obtaining all
underground utility locates.
Unless specifically agreed otherwise, the property owner
shall be responsible for final grading areas subsequently
depressed from soil settling. Property owner shall also be
responsible for revegetation of affected areas unless
specifically agreed otherwise.
Contractors installing wastewater disposal systems must
be certified by the Municipal Department of Health and
Human Services for system installations. Owners installing
their own systems must receive prior approval from D.H.H.S.
before beginning system installation.
SEPTIC TANK INSTALLATION
1. A septic tank is to be constructed
manufacturer. Construction shall
for pumping access.
by a certified septic tank
include two 4" cleanouts
2. The septic tank shall be sufficiently bedded to prevent
settling or shifting of the tank.
Lot 5, Block 2, Voyles Subdivision
January 31, 1995
Page Two
3. All standpipes on the septic tank shall extend a minimum of
12 inches above final grade.
4. Septic tanks installed without 4' of cover shall have a
minimum of 2" of direct burial insulation.
A foundation cleanout shall be installed one to four feet
from the building foundation. Two cleanouts shall be
installed between the tank and the drainfield. The first
cleanout shall be located on undisturbed soil not more than
10' from the tank. The first cleanout shall be to clean
toward the drainfield. The second cleanout shall be to clean
toward the tank.
6. Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
DRAINFIELD CONSTRUCTION:
The drainfield shall be constructed to the dimensions shown
on the design. The bottom of the bed shall be within 2" of
level. The bed shall not be installed on a slope greater than
10%.
Distribution piping must be placed level with perforations
down atop a level bed of drainfield rock. Rock should then
be placed over the pipe to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between
the drainfield rock and the natural soil backfill.
Monitor tubes must be 4" in diameter and installed at the
locations shown on the design, The portion below ground
must be perforated.
5. Contractor shall verify the septic tank and drainfield are a
minimum 100' away from any water wells in the area.
Lot 5, Block 2, Voyles Subdivision
Januaw 31, 1995
Page Three
Direct bury insulation must be placed over the distribution
system since less than 3' of backfill depth is available.
Finish grade over the bed must be mounded to prevent
settlement or depressions.
7. Grade area surrounding the absorption bed to drain away
from the bed.
A minimum 2' of accepting soil is required below the
drainfield rock. Contractor shall verify this condition prior
to placement of the rock. All pockets of unacceptable
materials must be removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a Municipally approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C.
(perforated and solid), ASTM F810 or H.D.P.E. (perforated, but
not solid) and ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial
polystyrene (Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
A permeable geotextile fabric (Typar, Mirafi or equal) must
be installed between the final drain rock layer and the
native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than
3% passing the #200 seive.
Lot 5, Block 2, Voyles Subdivision
Januaw 31, 1995
Page Four
INSPECTIONS:
A minimum of two inspections are required by Municipal
Ordinance. These inspections must be conducted under the
supervision of a professional engineer registered in the State
of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation
of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement
of the geotextile fabric, gravel, distribution piping,
standpipes, cleanouts and insulation. No backfill should be in
place at the time of inspection.
Contractor shall provide a copy of all field survey layout and
construction notes for use in preparing the certified as-built
of the completed system.
Parcel I.D.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us
(907) 343-7904
· CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A. SINGLE FAMILY DWELLING
51-064-67 HAA # O
Expiration Date:
GENERAL INFORMATION
Complete legal description .. Lot 5, Block 2, Voyles Subdivision
Location (site address or directions) 23501 Chandelle Drive
Current Property owner(s) Joe and Anita Roseman
Day phone 688-2511
Mailing address
P.O. Box 672203 Chufliak, AK 99567
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Un/ess othem, ise .requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: Four(4)
3. TYPE OF WATER SUPPLY:
Individual Well
Individual-Water-Storage-
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] ....................... Individual'Holding-tank- ............. I'~--
[] Community On-site I'"'1
[] Public Sewer ~
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health ,Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for 'a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class ^ or B wells or a'public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system'is(are) safe, functional and adequate for the number of '
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Engineering Phone 522.7773
Address' P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
DSD SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
Date 619/2004 · ·
bedrooms, with the following stipulatior~s:
Additional Comments
Note: The well for this property meets existing State and Municipal Codes. There are nitrates
present, it is suggested that perloQic testing be performed to insure the wells continued suitability.
CUrrent nitrate concentration is 6.14 mg/~. EPA maximum concentration is 10.0___mg/ii~i_-_M.0re ........
inforinatJan ~n --' .... ' .....
Attachments:
HAA Checklist
Septic Syste, m Advisory
Well Flow Advisory.
X
Maintenance Agreements
·Supplementai Engineer's RePort
Other
' Origin~l_Certifi~ate.Date:__~ ~_~-/-
(Rev. t2/00)
6-- 9--04; 6:06AM;
SGS Ref. fl ] 043059001
Client Name Anderson Engineering
Project Name/# 5/2 Voyles S/D
Client Sample ID Hose Bib
Matrix Drinking Water
Sample Remar~:
;907 5615301
All Dates/Times are Alaska Standard Time
Printed Date/Time 06/08/2004 8:24
Collected Date/Time 06/03/2004 10:10
Received Date/Time 06/03/2004 10:30
Technical Dir eclo r].~.~te p~~Ed e
Released~(~~~~---
Parameter
Results
PQL
Units Method
Container ID Allowable Prep Analysis
Limits Date Dare Init
Waters Department
Nil~'ate-N
~icrobiology Laboratory
Total Coliform
6.14
5 OB, No Coil
0.100
mg/L EPA 300.0
col/100mL SMI8 9222B
B ¢<= 1 O)
A
06/04/04
06/03/04 DKC
6- 9-04;
6:OSAM;
;907
5615301 ~ 3/
j~~ SGS/CT&E ENVIRONMEN+AL SERVICES
· Drinking Water ^nalysi Report for Total Coliform Bacteria
READ INSTRUCllONS ON REVERSE SIDE BEFORE COLLECTING SAMPL~
MUST BE COMPr'ETED BY WATER SUPPLIER
~:~U.BLIC WATER SYSTEM IDg -- . .
· [] PRIVATE WATER SYSTEM
~' Send Results · ~ Set, Invoice
Wine-~.y~m Na rne/Cam~ny Name ~lact 'Name
SAMPLE COLLECTION:
Month Day Year
TIme: /0; I ~ ~PM (~rc~o~el
T~nspo~ed
200 W. POTTER DRIVE'
ANCHORAGE, ALASKA 99518
Te1:.907-562-2343
Fax: 907-561-5301
' L~b Ref No. ,
1 043059 IA
[] Send Results Dsendlnvoke
SAM PLE TYPE:
i~f-Rouflne r'l Treated Water
[] RepeM Sample ' [] Untreated Water
'{refer t(~ lab n~. )
[] Special Purpose
to Lab By: (~. ame .as collector Other:,
TO BE COMPLETED BY LABORATORY
.Sample, Rbceivin.q:
Date:_ ~ISlO~
Time:
Temp:
Delivery Method:
Pnrffed Name
Comments:
[] Sample over 30 hours old;
Results may be unrellable
[] 48 Hour Waiver
Phone.#:
Fax #:
[] RUSH S~,MPLE
.Bacteriolo,qical Water Analysis Record; jsent'to ADEC:
MMO.MUG (I~IA) RESULTS: J ANC FBK JUN
~ {' JDate~lme:
Analyst: ~ Colt:
Jsent to Client:
Anal~l Method: MEMBRANE ~L~R RESULt: JPhoned
Oire~t C~n~ ~ Cdon~100mL JDate~e:
~ Membrane Filter Verir~5on: JS~ke
~ MMO-MUG (P/A) ,,~,~ . ~LTB:
-LB~B~ ' ~ Satisfacto~
~,~ [ EC:. ~ Unsatisfacto~
- S~nature Date~Ime;
\~petrakpublic~DOCUMENTtFORMS~Micro\Coli Form 121703.xls Form # FW- 0053 12/17/03
Municipality of Anchorage
Development Services Department
Building Safe.3, Division
On-Site Water and Wastewater Program
470.0 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE' OF HEALTH AUTHORITYAPPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-064-67
Expiration Date:'. ..~.
1:. GENERAL INFORMATION
Complete legal description Lot 5, Block 2, Voyles Subdivision
Lo(~ation (site address or directions) 23501 Chandelle Drive Chugiak, AK.
Current Property owner(s)
Mailing address
Lending agency
Joe & Anita Roseman
P.O. Box 672203 Chugiak, AK 99567
Day phone 688-25:11
Day phone
Mailing address'
Real Estate Agent
Day phone
e
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: Four (4)
TYPE OF WATER SUPPLY:
Individual Well []
· Individual Water Storage D
community Class ~ Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
IndNidUal Holding tank []
Community On-site · []
Public Sewer []
II
The Municipality of Anchorage Development Services Depadment (DSD) Issu.es Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority'Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be ~eissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
Sanitary seal r (Y/N
.~"' ,'~, !i~ il
ed to 195 ft.;
WATER SAMPLE RESULTS. - I~ l .... ~ I ' I I I
~'-,=,--.~ '~' '--,;,~,:--,~,~,-~n0~l~;~' trat~ t;~: : ,. ' Otherba ,fla' 0 colonies/100ml.
" Date of sample: :~12212004~ :,~ ,olect f ...... ...., , , .,.,,~ .I, ..,~
SEPTIC/HOLDING TANK DATA. , ,j ,J ~ t, : ;, , ~ .... - i ·
...... : , , ;' ' - ~ , ,, , ~ ~ , ,~ . ' ',~ .
, ' 'f . 9
Tank ~vne/Materi~l :, SepticlSte~l':; ~. ~ .,I ~:=' ~ ~. [:' i' ;~ :.;. Date.installe(I 819/~995 :.
Tank size ~4,250 :~ gal. ,; ~ , ;Nu~t )f Co~ ~ .. ,~ · Cleanguts (~/H):y
- _"_,_;'.;,~;~x,,. N/u~y · '. 'D( )ression ( ' (~ N " H ~hwater alarm (WN) N
DateOfou~oing~61~12003 r~ ~.~.~ ,~.~: t?Pumpen~JR's mp t~ J~ .,I ~.~, ~ ~ .
ABSORPTION FIELD DATA., ~ ' :' ~.':'i' + ~~ ' ..... '. ' '1 ' '~ · '
DateinstaledSI1111995 ':~ ~:[ Soil at g (g.p~d.?t2orft~/bdrm)',SgPD/SF ~. ~Sys~em,~yp~ ShallowBed
Total de~th ,1 ft.-~: . ~ "~Eff. absorpt 3n area 1 ~ft ~[Mon tor ng tube Y..De 3ress~on over
Pate0fad~u~cYtest'l12212004: .f,~.l.i~ .~ ~[i'F.esults~(E~:~/Fail)'.~S '..: ~ ',~' 'Forjbedrooms
.Fu~ddepth nabsorpton:fieldbeforetest0~; .~ :. ~ ~a~eradde~gal. I ~' ~ ~ Newdepth~n'
EapsedTime:~62min. ~ .::. ; Fnalfluiddeith0in: [~ ': ":~Absorpto rat( ~,=600 g.p.d.
. ,~ '. ; ' ~'T. :: : ~: . ~ ~ i ; :
. . ~, ~ . , ,; '~ ~ ,l~.l.t~' ,.,.~ :~ * ~ , ~r,~ I~,.~ ~I'I; ' ~ ' ; 'd ~' ~:] . ~ '
. Any rejuve~'ation treatment (past 12 ~o') (Y/N',~:~ype) 'iF[; ,I~i..-~: :~ :: '~ :-;..~" ~ ~,'glve aate.
..... , ,~, ~ ~.~.. ~. ':~ ~'. ~ .;;;~,; r ~ . ~ , ~= ,
~88~'
~ ~ ~- 0
0o
>o {
~ OOooooo~ § ~
i oooooooog ~'0
]
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P,O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA# ' ~
1. GENERAL INFORMATION
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
5. STATEMENT OF iNSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or Wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm /.:.~,, c. -_t., ~-:,-., ~:/~;c-%~L,:~,,:~- Phone
Address PC', L~t: x. ~- t75 f~.;.'~ /~'~
DHHS SIGNATURE
~ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
By:
A ....' IA mments Note The well for this property meets existing
¢]QIt,ona tj . ' ,= ' ~' o~ ~ It ~
Shate an~ Municipal Cod. es. ?her.. are n~trates p~e~.n~. ~s
suq~ested that a perJ_odic testing be performed to insure the wells
contiDued s~itability. Nitra%e concentration is 5,5 mg/1. EPA
,~,~,, ;' , . / v 11~'% Date '
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfl/certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72~25 (Rev 1/91) Back MOA #21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description:
A. !NELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/ItOLDING TANK DATA
Date installed
Foundation cleaoout (Y/N)
Date of Polnping
C. ABSORPTION FIELD DATA
Date installed
it
Leagth ~> ~ Width
Parcel I.D.:
IfA, B, or C. attach ADEC letter. ADEC water systeln number
Date completed ~'/~.S~
Casco to l q~-- ~ Casing height (above ground)
y Wires properly protected fY/N)
FROM WELL LOG AT INSPECTION
5/0-5'
Ibq~
Gravel thickness below pipe ,, ~ t Total depth
t &
Effective absorption area I, ZOO ~Monitoring Tube present(Y/N) Y Depression over field (Y/N) ~
Date of adequacy test fiJO, O ~_~0~d'37" Results (Pass/Fail) ~'~,'~g For ~C:~O ~L_. bedrooms
Fhdd depth in absorption field before test (in.);
Fluid depth ,"d//A Minutes later: r,~/~
Peroxide treatment (past 12 months) (Y/N)
(2 hnmediately ,after ,'4/P, gal. water added (in.):
(in.) Absorption rate = ~/dO g.p.d.
/'] If yes, give date
Nitrate .~'. S- ~'~'/~//~ Other bacteria O
Collected by: ~. k]/¥RA/.~
Tank size /, L~O Number of Compamnents g-, Cleanouts (Y/N)__
Depression (Y~) ~ High water alarm (Y~) ~
Pompcr ~Ot0 ~'t~C~l O~
Y
Soil rating (g.p.d./fl2 or ft2/bdrm) ~ ~ Systeln type
[~ g.p.m g.p,m.
X):~JJ&q~TATION
Date installed
Manhole/Access (Y/N) _
High water alam~ level at*
Cycles tested
Size in gallous
~,,p~~ "Pump off" level at*
*Datum ~.~.._.~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holdiug tank on lot
Absorption field on lot
Pnblic sewer main /64 1 LA-rS
Sewer/septic service line '>
; On adjacent lots
; On adjacent lots
Pnblic sewer mauhole/clcanout
LLft station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation Z~' Property line ID ~- t Absorption field
Water main/service line '~$~F_) ~ Surface water/drainage 2'//) 0 ~ Wells ou adjacent lots
>100~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Buildiug foundatiou
Surface water
Curtain drain
Water malty'service line .> 55'0 t
Driveway. parking/vehicle storage area > G-cO '
Wells on adjacent lots ~> I O O t
ENGINEER'S CERTIFICATION -.
I certify that I have determined thrufield inspections and review of Municipal records that the above s~'s~etns are
in conformance with MOA I[AA guidelines in effect on this date.
Engineer's Name
Date t ~ t Z /
HAA Fee $
Date of Payment
Receipt Number
~O0. bO
10/I,~/q~'
Waiver Fee $
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc